#nerve blocks

Nerve Blocks :(

Anytime people talk about “pain clinic” this issue keeps coming up. For a reason unbeknownst to me, patients are expected to submit themselves to needling. Often these injections are performed on a weekly basis yet providing either zero or a very short-term pain relief. For the sake of argument, placebo effect will not be discussed here, although, certainly there is a lot to do with the so-called expected effect.

Physiologically, injected local anesthetics (hopefully, without corticosteroids) produce some pleasant warming numbness and muscle relaxation. Rarely, they produce long-lasting pain relief, but the mechanism is not clear yet. We can speculate that when these drugs are injected very close to the target nerve, or into the nerve, they cause neurotoxicity (poisoning) and slow conduction of electric impulses through this nerve. There is another hypothesis of a so-called “pain reset,” some magical Microsoft-like solution: if something doesn’t work and you don’t know what to do, just click "restart". There is also a strong belief that with repeated nerve blocks thepain will be diminishing. All these hypotheses have never been experimentally confirmed. On the other hand, tissue toxicity was documented in laboratory studies, and conscientious ethical pain physicians published their experience disproving nerve injections (Arne Johansson and Bengt Sjolund. J Pain Symptom Manage 1996).

Thus, we barely have something good, possibly have something bad, but sure enough, there is an ugly there. There is an inconvenient truth related to the fee for services system where doctors are paid per injection. Because, a single injection is not paid well, they do 6-12 needle punctures, injecting stuff into various unrelated and not united by sound diagnosis anatomical structures. I hope some of my colleagues do this because they believe in this ritual. They were educated by older and imminent needle jockeys and genuinely consider “drill-mill” to be an equivalent of Pain Medicine. Maybe they are just blessed with ignorance? Regrettably, I doubt they are blessed, I gather they are cursed by one of the worst sins, the greed. I refuse to believe they would apply “My Mom's Principle” but rather they push a fundamental principle, “Do No Harm” into the deepest drawer of their mind. The excuse is:  “it is common practice, and everyone is doing it.” This is true, but is it right?

Surprisingly, the regulations are very forgiving, and in the absence of evidence against this, the multiple no sense nerve blocks are considered the standard of care. All that is needed is to obtain a permit specifically allowing clinics to implement these injections in their practice. Interestingly, no special permission is required for other injections, such as joint aspirations. Perhaps, if someone comes with a swollen knee, offering an injection in the shoulder would be odd. However, when the low back hurts, no one asks why 10-12 injections are being performed.

We always say our Canadian system is not ideal, but at least we don’t do unnecessary treatments as Americans do. Well, in this case, our system is much worse. Certainly, some American doctors may also turn patients into pincushions to fill their bank accounts, but the American Society of Anesthesiologists recommended against nerve blocks for chronic pain other than for diagnostic purposes a long time ago. In the absence of the similar position here, and when nonsense declared as an appropriate and medically necessary method, patients should ask their doctor: “will you do it to your Mom?” and watch their facial expression.